CPT 99204 carries a 2026 work RVU of 2.60, with a non-facility practice expense (PE) RVU of 2.47, a facility PE RVU of 0.66, and a malpractice (MP) RVU of 0.24. That produces a national non-facility total RVU of 5.31 and a national facility total RVU of 3.50, before any locality adjustment is applied.
What CPT 99204 Represents
CPT 99204 is a new patient office or outpatient evaluation and management (E/M) visit, positioned above 99203 and below 99205 in the new-patient E/M family. Like the rest of the office/outpatient E/M code set, its documentation requirements can be met either through medical decision making (MDM) level or total time on the date of the encounter, depending on the applicable CPT guidelines. This page addresses the RVU and payment side of the code — it does not determine whether a specific encounter should be billed as 99204 instead of 99203 or 99205, since that depends on documentation, MDM complexity or time, and payer policy.
99204 RVU Components (2026)
Each CPT and HCPCS code on the Medicare Physician Fee Schedule (MPFS) is assigned three separate RVU components, and it’s the combination — not any single number — that drives Medicare payment.
| Component | What it measures | 99204 value |
|---|---|---|
| Work RVU (wRVU) | Physician time, skill, effort, and judgment | 2.60 |
| Non-facility PE RVU | Overhead, staff, and supplies when the practice bears facility costs (e.g., a private office) | 2.47 |
| Facility PE RVU | Overhead when the visit occurs in a hospital or facility setting that bills its own facility fee | 0.66 |
| Malpractice (MP) RVU | Professional liability insurance cost allocated to the service | 0.24 |
| Non-facility total RVU | Sum of work + non-facility PE + MP | 5.31 |
| Facility total RVU | Sum of work + facility PE + MP | 3.50 |
The gap between the non-facility and facility totals (5.31 vs. 3.50) comes entirely from the PE RVU, not the work RVU. Work RVU stays fixed at 2.60 regardless of where the visit happens, because it reflects the physician’s own effort — the setting only changes who is absorbing the overhead cost.
Work RVU vs. Total RVU vs. Payment RVU
This distinction is where a lot of confusion happens, so it’s worth stating precisely:
- Work RVU measures physician effort only. It’s the number most physician compensation plans reference when they quote a “dollars per wRVU” rate.
- Total RVU (work + PE + MP) is what Medicare actually multiplies against the conversion factor to calculate a claim payment. Total RVU, not work RVU, is the payment-driving figure under the MPFS.
- wRVU-based compensation and Medicare reimbursement are two separate financial systems that happen to share the same underlying CMS data set. A practice can pay a physician a contract-defined dollar amount per wRVU generated even though Medicare’s actual payment for that visit was calculated from the total RVU. Do not assume 1 wRVU corresponds to a fixed dollar amount of Medicare payment — it doesn’t, because PE and MP RVU, GPCI, and the conversion factor all move independently of work RVU.
How Medicare Payment Is Calculated
Medicare’s national payment formula geographically adjusts each RVU component separately before applying the conversion factor:
Total RVU (geographically adjusted) =
(Work RVU × Work GPCI) + (PE RVU × PE GPCI) + (MP RVU × MP GPCI)
Medicare Payment = Total RVU (geographically adjusted) × Conversion Factor
The Geographic Practice Cost Index (GPCI) exists because labor, rent, and malpractice premiums differ by locality. A physician in Manhattan and a physician in rural Kansas can bill the identical CPT code and receive different Medicare payments purely because their GPCI values differ — the CPT RVU components themselves don’t change, only the geographic multiplier does. RVUinUSA’s GPCI calculator lets you apply a specific locality’s GPCI set to any code’s RVU components before running the payment math.
National (GPCI = 1.0) Example for 99204
At national GPCI values, the geographic adjustment step nets out, so the total RVU equals the unadjusted RVU. For 2026, CMS finalized two separate conversion factors for the first time: one for clinicians who are Qualifying APM Participants (QPs) and one for everyone else (non-QPs). The non-QP conversion factor is $33.4009, and the QP conversion factor is $33.5675.
Using the non-QP conversion factor:
- Non-facility: 5.31 total RVU × $33.4009 ≈ $177.36
- Facility: 3.50 total RVU × $33.4009 ≈ $116.90
These are national estimates only. Actual claim payment depends on locality GPCI, the clinician’s QP/non-QP status, and any applicable sequestration or budget-neutrality adjustments that CMS applies outside the base RVU calculation. Run the same inputs through the RVU calculator to see how a specific locality changes the result.
Comparing 99204 to Adjacent New Patient Codes
99204 sits in the middle of the new patient E/M family. Comparing RVU and payment values across 99203, 99204, and 99205 is useful for understanding the financial step-up between levels, but the comparison should never be used backward to select a code — MDM complexity or time is what determines the correct level, and RVU output is simply what follows once that determination is made.
| CPT | Work RVU | Non-facility total RVU | National non-QP payment estimate (2026) |
|---|---|---|---|
| 99203 | 1.60 | 3.52 | ~$117.57 |
| 99204 | 2.60 | 5.31 | ~$177.36 |
| 99205 | 3.50 | 7.09 | ~$236.81 |
Note that 99205’s work RVU is 3.50 in the 2026 RVU data. Keep work RVU separate from total RVU and facility/non-facility payment estimates when comparing 99204 with 99205.
Each step up the ladder roughly adds around 1.0 work RVU and 1.6–1.8 total RVU, which is a meaningful jump in both productivity credit and Medicare payment — one reason undercoding a visit by even one level has a measurable financial effect across a high new-patient-volume practice.
99204 vs. 99214: Different Visit Types, Not Interchangeable Levels
99204 and 99214 are frequently searched together because both sit at the “moderate complexity” tier of office E/M coding, but they answer different clinical questions: 99204 is for a new patient, 99214 is for an established patient. They are not substitutes for each other regardless of RVU value.
| CPT | Patient type | Work RVU | Non-facility total RVU |
|---|---|---|---|
| 99204 | New patient | 2.60 | 5.31 |
| 99214 | Established patient | 1.92 | 4.06 |
99204 pays more per encounter than 99214 largely because evaluating a new patient — with no existing chart, history, or established treatment plan — requires more physician work and practice resources than a follow-up visit. That RVU gap reflects workload, not a signal to code an established patient visit as “new” to capture higher reimbursement. For a deeper breakdown of the established-patient tier, see the 99213 vs. 99214 comparison.
Using 99204 in Physician Compensation Modeling
For productivity-based compensation, 99204 contributes its 2.60 work RVU toward a physician’s credited total — but only if the employment agreement actually credits new patient visits under the CMS RVU schedule the contract references. Before using 2.60 wRVU in a compensation projection, confirm:
- Which CMS RVU data year the contract uses (RVU values change annually, and a contract that “freezes” to an older schedule year will produce different wRVU totals than the current-year table).
- Whether the compensation formula pays per wRVU generated, per total RVU, or via a blended collections-based model.
- Whether new-patient visit thresholds, modifiers, or split/shared billing rules affect whether the full 2.60 wRVU is credited to one physician or split among providers.
Because Medicare payment uses total RVU with GPCI and conversion factor adjustments, while most compensation plans use work RVU against a flat dollar rate set in the contract, the two dollar figures — Medicare’s ~$177 estimate and a physician’s wRVU-based compensation credit — are calculated through entirely separate mechanics and should never be equated. Use the salary calculator to model wRVU-based compensation separately from the Medicare payment estimate above, and check contract terms against the Contract Red Flags Guide before assuming a quoted wRVU rate reflects actual Medicare reimbursement.
Practical Workflow for Using This Data
- Confirm the CMS RVU data year you’re working from — RVU values for E/M codes have changed nearly every year as CMS updates its physician time and PE methodology, including the 2026 update that increased 99204’s total RVU from 5.05 (2025) to 5.31 (2026).
2. Choose facility or non-facility PE RVU based on where the visit actually occurred.
- Apply locality GPCI values through the GPCI calculator rather than relying on the national (GPCI = 1.0) estimate for actual claim-level payment expectations.
- Apply the correct 2026 conversion factor — $33.4009 for non-QP clinicians or $33.5675 for Qualifying APM Participants — since using the wrong one changes every downstream payment estimate.
- If the goal is compensation modeling rather than Medicare payment estimation, switch to work RVU only and apply the contract’s dollar-per-wRVU rate instead of the conversion factor.
RVU and payment figures on this page reflect the 2026 CMS Physician Fee Schedule data set as currently published; because CMS updates RVU values, GPCI factors, and the conversion factor annually — and sometimes mid-year through corrections — always verify current-year figures against the official CMS Physician Fee Schedule Look-Up Tool before using them for billing, contracting, or compliance decisions.